- The Plan generally covers only medically necessary care and services.
- Inpatient hospital stays must be precertified for maximum benefit allowed by the Plan.
- The Medical POS II network of participating providers offers you savings in both time and money.
- Preventive care provisions help you stay healthy.
- The Plan offers you the opportunity to have your benefits determined before a procedure is performed.
Expenses are covered under these options only if they are medically necessary. Care is medically necessary if it is a therapeutic procedure, service or supply used in the medical treatment of an injury, disease, or pregnancy, which is generally recognized by the United States medical community as appropriate. Claims are reviewed as submitted, and some or all of any claim or series of services could be denied as not being medically necessary. It also means that experimental or investigational procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions for limited exceptions.
For non-emergency medical care (including for mental health and substance abuse):
- If you are using a POS II network provider, or a mental health PPO network provider, your provider will handle the precertification process for you.
- Before you are admitted to a hospital that does not participate in the Aetna POS II or the Magellan Mental Health PPO network, you must call Aetna for a medical pre-admission review or Magellan for a mental health pre-admission review. This is required for most inpatient admissions, including extended-care facilities.
You are not required to call to pre-certify:
- Hospitalization outside the United States, for both medical and mental health or substance abuse.
- Extended care facility.
- Skilled nursing facility.
- Private duty nursing.
- Defibrillators and pacemakers not a result of emergency treatment.
- Heart catheterizations.
- Cardiac rhythm implantable devices.
- Spinal fusion surgery and other spinal procedures.
Enhanced clinical review:
The Plan also includes a utilization management program, known as Enhanced Clinical Review, of some diagnostic services (e.g., MRIs, CT Scans, Cardiac Imaging, sleep studies, hip/knee replacement procedures, etc.).
An enhanced clinical review is a mandatory review of select covered services that have equivalent, lower-cost alternatives, to ensure the higher cost service is medically necessary in advance of treatment. If the review is not completed and the treatment is not approved, it will not be covered under the Plan.
Please contact Aetna Member Services to determine if the service your physician has recommended requires enhanced clinical review.
The ECR precertification process applies to Aetna participating providers and facilities. Non-network providers and facilities are subject to retrospective claim reviews to determine if the services meet Aetna medical necessity guidelines.
For emergency inpatient admissions:
- If you are using a POS II network provider, your provider will obtain certification for you.
- You or someone acting on your behalf must call to certify care if you are in a non-network or out-of-network area hospital.
For mental health or substance abuse care:
For certain prescription drugs:
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the Plan will cover another (usually more expensive) drug.
Additionally, as part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless precertified by Express Scripts, based on medical evidence submitted by your physician.
A predetermination is an estimate of covered services and benefits payable in advance of treatment. It is not a guarantee of benefits eligible or payment amount. You may request a predetermination for any covered service. In most cases, you may receive an answer over the phone. In other cases, information from your provider may be needed. You or your doctor can also request a predetermination of benefits, in writing, before the service is performed. Predetermination is recommended for all outpatient surgical procedures.
This predetermination may require review by one or more doctors. Be sure to allow time for this review between the predetermination request and the proposed date of the service. By obtaining the written response, you will have more detailed information about the level of reimbursement.
For more information on requesting a predetermination, see the Information sources section at the front of this SPD.
- Primary participant's name and member ID, which can be found on your Aetna ID card,
- Patient's name,
- Complete description of medical services or surgical procedures. If possible, include the diagnosis code(s) and the five-digit Current Procedural Terminology (CPT) codes or the Healthcare Common Procedure Coding System (HCPCS) alpha-numeric codes, which you can get from the provider,
- Provider's complete information including name, address, zip code and phone number, and
- Provider's proposed fee for each service.
Medical / surgical POS II network (also see mental health and substance abuse section)
- You pay a copay for most office visits, including diagnostic laboratory and X-rays associated with that office visit. Preventive care office visits are reimbursed at 100%.
- Emergency room physician expenses, in-patient hospital expenses, and outpatient surgery expenses are subject to deductible and coinsurance.
- Other expenses such as home health care, durable medical equipment or complex imaging are reimbursed at the network reimbursement level (either 80% for the POS II B or 75% for the POS II A) of a negotiated rate after you meet the annual deductible.
- Your annual out-of-pocket maximum is significantly lower.
- Medical POS II network providers file claims and handle the hospital pre-admission review process for you.
- All negotiated charges are within reasonable and customary limits.
POS II networks are located throughout the United States. As explained in the Introduction, the Medical POS II is part of the Aetna Choice® POS II network.
You are a network participant if you live in a POS II area. These are some of the Medical POS II areas:
- Beaumont, Texas
- Baton Rouge, Louisiana
- Dallas, Texas
- Houston, Texas
Benefits Based on the Network Status of the Provider
Copayment for office visits/lab work when provided by a primary care physician; higher copayment when provided by a specialist.
Is your doctor a network provider?
Show your ID card
If you live in a medical POS II network area and do not use medical POS II network providers
- Your out-of-pocket costs will generally be higher. The Plan's reimbursement level is 60% for the POS II B and 55% for the POS II A of reasonable and customary charges, after you satisfy the non-network deductible, and your out-of-pocket expenses will accumulate towards a higher non-network out-of-pocket maximum.
- You must call Aetna to initiate the medical pre-admission review process for inpatient treatment and ensure any precertification or preauthorization requirements are completed.
- If your provider or facility charges are above reasonable and customary limits, you are responsible for paying any amounts above reasonable and customary limits in addition to your deductible and/or coinsurance. You may be balance billed by the provider or facility for any amount not reimbursed by Aetna.
- You are responsible for submitting claims.
If you cannot find a Network Provider (network deficiency)
Sometimes you may have difficulty finding a network provider in your area that is available when you need care. If an Aetna Choice® POS II network provider is not available for medical/surgical services, call Aetna Member Services for information on the Plan's alternate network deficiency benefit. If Aetna confirms a network provider is not available for the medical/surgical services you need, they will authorize use of a designated non-network provider for your care.
If you cannot find an available Mental Health PPO network provider in your area for behavioral health services or substance abuse treatment you need, call Magellan to request a single case agreement. If Magellan confirms a network provider is not available for the behavioral health services or substance abuse treatment you need, they will arrange for a single case agreement with a designated non-network provider for your care.
Benefits for covered services at a designated non-network provider under the alternate network deficiency benefit will be paid at the In-Network level (either 80% for POS II B or 75% for POS II A of reasonable and customary charges) after the plan year deductible has been satisfied, and out-of- pocket expenses for those services will accumulate towards your In-Network out-of-pocket maximum. Copayments will not apply.
If you live outside a POS II network area (out-of-network area benefits)
If you live outside a designated POS II network area, benefits for covered services are paid at the out-of-network area benefit level.
You still have access to Aetna Choice® POS II network providers and facilities in your area, within a short driving distance, and while travelling. When you receive care from a network provider or in a network facility, you will be reimbursed at 80% for POS II B or 75% for POS II A of the negotiated network rate for inpatient and outpatient services, your network provider will initiate the pre-admission review process, and network copayments for primary care and specialist office visits will apply.
If you live outside a POS II network area and receive care from a non-network provider or in a non-network facility, you will be reimbursed at 80% for POS II B and 75% for POS II A of reasonable and customary charges for similar services in the same area. Network discounts and network copayments do not apply, and you must satisfy the deductible for all covered services other than preventive care. You are also responsible for initiating the medical pre-admission review process for inpatient treatment unless you use a network provider.
Most non-network charges fall within reasonable and customary limits. However, you may receive a balance bill for the difference between a non-network provider’s billed charges and what is considered reasonable and customary for covered services in your area. If this happens, call Aetna Member Services. The full or partial balance bill may qualify as an allowable expense eligible for payment by the Plan. This includes balance bills for ambulance services, emergency physicians, radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, and intensivists. It may also include balance bills for scheduled procedures performed by a non-network physician when a network physician is not available. However, if a network physician is available and you schedule an inpatient or outpatient procedure with a non-network physician, you will be responsible for any billed charges above reasonable and customary limits, which for professional services is set at 200% of Medicare Fee Schedule of charges for similar services in the same geographic area.
If you live outside a POS II network area, the out-of-pocket maximum for non-network services is the same as the maximum for network services. Once your annual out-of-pocket limit is reached, covered services are reimbursed at 100% of reasonable and customary charges.
Note: You are responsible for payment for services that are not covered by the Plan, including non-medical ancillary services and any balance bill that remains after adjustments for allowable expenses have been made. Payments for services not covered by the Plan do not accumulate towards your annual out-of-pocket limit.
If you live in an out-of-network area and incur claims outside of the U.S., reimbursement is paid at either 80% for POS B or 75% for POS A of billed charges after deductible. There is no reasonable and customary profiling for foreign providers.
If you receive an unexpected bill from a Non-Network Provider
Sometimes covered services are performed by a non-network provider without your knowledge or ability to choose a participating provider, for example in an emergency situation or when you receive care in a network facility but a network physician is unavailable. When this happens, charges are limited to what is considered reasonable and customary for similar services in the same geographic area, and you will be reimbursed at the network benefit level (either 80% for POS II B or 75% for POS II A), after the plan year deductible has been satisfied.
Most non-network charges will fall within reasonable and customary limits. However, if you receive a balance bill for the difference between a non-network provider’s billed charges and what is considered reasonable and customary for covered services under the POS II option, and you did not voluntarily elect to receive services from the non-network provider, call Aetna Member Services. The full or partial balance bill may qualify as an allowable expense eligible for payment by the Plan. This includes balance bills for ambulance services, emergency physicians, radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, and intensivists. It may also include balance bills for scheduled procedures performed by a non-network physician when a network physician is not available.
An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
- Serious impairment to bodily function, or
- Serious dysfunction of any bodily organ or part.
Some examples of emergencies are:
- Heart attack or suspected heart attack.
- Uncontrolled or severe bleeding.
- Suspected overdose of medication.
- Severe burns.
- High fever (especially in infants).
- Loss of consciousness.
Some common examples of non-emergencies are:
- Routine exams and immunizations.
- Ear Infections.
- Colds and Flu.
Reimbursement for emergency services
Reimbursement for non-emergency services
If you go to a non-network emergency room and your condition is determined to be non-emergency, then the expense may be subject to the non-network level of reimbursement (either 60% for the POS II B or 55% for the POS II A), after the plan year deductible has been satisfied
Your physician may direct you to an Urgent Care Center as an alternative to a hospital emergency room when he or she feels it is appropriate to do so. If you or a family member receive care at a network urgent care center, you will pay the applicable copay, equal to the specialist physician copay under your plan option, and the Plan pays the remaining charges. If you live in a network area, and you use a non-network urgent care center, you will be reimbursed at the non-network level (either 60% for the POS II B or 55% for the POS II A), after the plan year deductible has been satisfied. If you live in an out of network area, you will be reimbursed at the out of network area level (either 80% for the POS II B or 75% for the POS II A) after you have met your deductible.
Telemedicine services are available via phone, web, or mobile app, 24 hours/day, 7 days/week through the Plan’s designated service provider (Teladoc). Teladoc’s health care professionals can evaluate, diagnose, and treat non-emergency medical and behavioral health conditions, such as cold/flu symptoms, stomach aches, common childhood illnesses, depression, stress, and anxiety. To register for services, call 855-835-2362 or visit www.Teladoc.com/Aetna.
Care while traveling
If a covered family member lives away from home
If you live in a Medical POS II network area and you have a covered family member who lives away from home (for instance, you have a child away at school), your family member's ZIP code determines the level of benefits the Plan pays.
Call Aetna Member Services with your family member's ZIP code to find out if Aetna has a Choice® POS II network in the area. If a network is there, you can contact Aetna Member Services, choose Find a Doctor on Aetna’s member website (www.aetna.com), or launch the Aetna mobile app to identify providers in the area. Here is how benefits are determined:
- If your family member receives care from a network provider, benefits will be paid at the network level.
- If your family member lives in a Medical POS II network area but uses non-network providers, benefits are paid at the non-network level.
- If your family member lives in an area where the Medical POS II network is not available and receives care from a non-network provider, benefits are paid at the out-of-network area level — regardless of whether you live in a network or out-of-network area — if you have notified Aetna of your family member's address.
Upon request, Aetna Member Services will provide an identification card for your family member.
Preventive carePreventive care services will be covered at 100%. If you use a non-network provider or live in a location where there is not a Medical POS II network, reasonable and customary charges for covered preventive care services will continue to apply. Preventive care services covered at 100% include the following:
- Breastfeeding durable medical equipment
- Lactation support and counseling
- Obesity prevention counseling
- Tobacco prevention counseling
- Drug and alcohol counseling
- Routine Immunizations including immunizations received at a pharmacy
- Prostate-Specific Antigen Test (PSA)
- Digital Rectal Examination (DRE)
- Routine Adult Physical
- Routine Mammography
- Routine GYN Exam
- Routine Well Baby Exam (includes hearing exam if under age seven)
- Routine Well Child Exam (includes hearing exam if under age seven)
- Colorectal Cancer Screening
- Double Barium Enema
- Fecal Occult
To receive preventive care benefits, the doctor's bill must indicate that the service is preventive in nature. If you are found to have a condition requiring additional treatment, the additional covered services will be paid after you meet any remaining annual deductible.